Report Bullying or Discrimination
It is the policy of the Waverly-Shell Rock Community School District not to illegally discriminate on the basis of race, color, national origin, sex, disability, religion, creed, age (for employment), marital status (for programs), sexual orientation, gender identity and socioeconomic status (for programs) in its educational programs and its employment practices. Please complete the attached form if you feel that you have or anyone you know has been a victim of discrimination or bullying.
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Name of person completing the form:
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Your answer
Phone number:
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Name of the complainant:
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Your answer
Name(s) of the accused:
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Your answer
Date(s) the incident occurred or was reported.
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Where did this occur?
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Your answer
Please explain the specific events that happened:
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Please list any witnesses to this specific event:
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Is there any physical evidence or the event (social media post, videos, documents etc.)
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Have you reported this information to anyone else? If so, whom and when?
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Your answer
By submitting this form I agree that the information provided in this complaint is true and correct to the best of my knowledge. I am willing to cooperate fully in the investigation of my complaint and provide whatever evidence Waverly Shell Rock School District deems relevant.
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